Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180

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Journal of Obsessive-Compulsive and Related Disorders

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Relationship obsessive compulsive disorder (ROCD): A conceptual framework

Guy Doron a,n, Danny S. Derby b, Ohad Szepsenwol a a School of Psychology, Interdisciplinary Center (IDC) Herzliya, P.O. Box 167, Herzliya 46150, Israel b Cognetica – The Israeli Center for Cognitive Behavioral Therapy, Tel Aviv, Israel article info abstract

Article history: Obsessive compulsive disorder (OCD) is a disabling and prevalent disorder with a variety of clinical Received 11 July 2013 presentations and obsessional themes. Recently, research has begun to investigate relationship-related Received in revised form obsessive–compulsive (OC) symptoms including relationship-centered and partner-focused OC symp- 21 November 2013 toms. In this paper, we present relationship obsessive–compulsive disorder (ROCD), delineate its main Accepted 3 December 2013 features, and describe its phenomenology. Drawing on recent cognitive-behavioral models of OCD, social Available online 17 December 2013 psychology and attachment research, we present a model of the development and maintenance of ROCD. Keywords: The role of personality factors, societal influences, parenting, and family environments in the etiology Obsessive compulsive disorder and preservation of ROCD symptoms is also evaluated. Finally, the conceptual and empirical links Relationships between ROCD symptoms and related constructs are explored and theoretically driven assessment and Relationship obsessive compulsive disorder intervention procedures are suggested. Relationship-centered obsessions & Partner-focused obsessions 2013 Elsevier Ltd. All rights reserved. Attachment Self ROCD

1. Introduction David and Jane suffer from what is commonly referred to as relationship obsessive compulsive disorder (ROCD) – obsessive– David, a 32-year-old business consultant living with his partner compulsive symptoms that focus on intimate relationships. Obses- for 3 months, enters my office and describes his problem: “I0ve sive compulsive disorder (OCD) is an incapacitating disorder with been in a relationship for a year, but I can0t stop thinking about a wide variety of obsessional themes including contamination whether this is the right relationship for me. I see other woman on fears, fear of harm to self or others, and scrupulosity (Abramowitz, the street or on Facebook and I can0t stop thinking whether I will McKay, & Taylor, 2008). Relationship obsessive compulsive dis- be happier with them, or feel more in love with them. I ask my order (ROCD) refers to an increasingly researched obsessional friends what they think. I check what I feel for her over and over theme – romantic relationships. ROCD often involves preoccupa- again, whether I remember her face, whether I think about her tions and doubts centered on one0s feelings towards a relationship enough. I know I love my partner, but I have to check and recheck. partner, the partner0s feelings towards oneself, and the “rightness” I feel depressed. I can0t go on like this”. Jane, a 28 year-old of the relationship experience (relationship-centered; Doron, academic in a 2-year relationship, recently moved in with her Derby, Szepsenwol, & Talmor., 2012a). Relationship-related OC partner. She describes a different preoccupation: “I love my phenomena may also include disabling preoccupation with the partner, I know I can0t live without him, but I can0t stop thinking perceived flaws of one0s relationship partner (partner-focused; about his body. He does not have the right body proportions. I Doron, Derby, Szepsenwol, & Talmor., 2012b). ROCD symptoms know I love him, and I know these thoughts are not rational, he include a wide range of compulsive behaviors such as repeated looks good. I hate myself for having these thoughts, I don0t think checking (e.g., of one0s own feelings), comparisons (e.g., of looks are all that important in a relationship, but I just can0t get it partners0 characteristics with those of other potential partners), out of my head. The fact that I look at other men also drive me neutralizing (e.g., visualizing being happy together) and reassur- crazy. I feel I can0t marry him like this. Why do I always have to ance seeking. ROCD obsessions and associated compulsive beha- compare his looks to other men0s?”. viors lead to severe personal and dyadic distress and often impair functioning in individuals0 social, occupational or other important areas of life.

n This paper outlines a theory of ROCD and reviews recent findings. Corresponding author. Tel.: þ972 9 960 2850. E-mail address: [email protected] (G. Doron). We argue that consideration of this obsessional theme may lead to a

2211-3649/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jocrd.2013.12.005 170 G. Doron et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180 broader understanding of the development and maintenance of The age of onset of ROCD is unknown. In our clinic, clients OCD, especially within a relational context. Relationship-related presenting with ROCD often report the onset of symptoms in early obsessive–compulsive symptoms may occur in various types of adulthood. In such cases, ROCD symptoms seem to persist relationships including people0s relationship with their parents, throughout the individuals0 history of romantic relationships. children, mentors, or even their God. In this paper, however, we Some individuals, however, trace back the onset of their ROCD will refer to ROCD within the context of romantic relationships. symptoms to the first time they faced commitment-related Consistent with prior OCD-related theoretical work (e.g. Doron & romantic decisions (e.g., getting married, having children). Kyrios, 2005; Rachman, 1997; OCCWG, 1997), we propose several Although ROCD symptoms can occur outside of an ongoing processes involved in the development and maintenance of ROCD romantic relationship (e.g., obsessing about past or future relation- and review initial evidence for their role in relationship obsessive– ships), such symptoms seem to be most distressing and debilitat- compulsive phenomena. We also argue that socio-cultural factors, ing when experienced in the course of an ongoing romantic early childhood environments, and parent–child relationships, influ- relationship. In community samples, ROCD symptoms were not ence the development of dysfunctional cognitive biases, self-percep- found to significantly relate to relationship length or gender tions, and attachment representations relevant to ROCD. Thus, this (Doron et al., 2012a,2012b; Doron, Szepsenwol, Karp, & Gal., 2013). paper aims to extend the focus of current OCD research by exploring The dyadic context provides abundant triggers of relationship- potential distal and proximal vulnerability factors that might con- centered and partner-focused OC phenomena. Nevertheless, for tribute to the development and maintenance of ROCD-related some individuals, ROCD symptoms may be activated by the dysfunctional beliefs and symptoms. termination of a romantic relationship. In this case, people may report being obsessively preoccupied with their previous partner “being the right one” and “missing the ONE”. Such cases are frequently associated with extreme fear of anticipated regret and 2. Relationship obsessive compulsive disorder (ROCD): are commonly accompanied by self-reassuring behaviors (e.g., phenomenology recalling the reasons for relationship termination), compulsive comparisons (i.e., with current partners), and compulsive recollec- ROCD is manifested in obsessive doubts and preoccupations tion of previous experiences (e.g., relationship conflicts). Other regarding romantic relationships and compulsive behaviors per- people report avoiding romantic relationships altogether for dread formed in order to alleviate the distress associated with the of hurting others (e.g., “I will drive her crazy”; “It will be a lie”)or presence and/or content of the obsessions. Relationship obsessions fear of re-experiencing ROCD symptoms. For instance, clients may often come in the form of thoughts (e.g., “is he the right one?”) report avoiding second dates for years for fear of obsessing about and images of the relationship partner, but can also occur in the the flaws of their partners or their partners becoming overly 0 form of urges (e.g., to leave one s current partner). Compulsive attached to them. behaviors in ROCD include, but are not limited to, repeated checking of one0s own feelings and thoughts toward the partner or the relationship, comparing partner0s characteristics or beha- 3. Measures of relationship obsessive–compulsive symptoms viors to others0, visualizing or recalling positive experiences or feelings, reassurance seeking and self-reassurance (see Table 1). A quick search on Google would show the term ROCD has been Relationship-related intrusions are often ego-dystonic as they frequently used in the last several years mainly on peer-support contradict the individual0s subjective experience of the relation- OCD forums. Systematic research, however, requires precise defi- ship (e.g., “I love her, but I can0t stop questioning my feelings”)or nitions and valid measurement tools. Recently, two measures were his or her personal values (e.g., “appearance should not be developed and validated for this purpose: the relationship obses- important in selecting a relationship partner”). Such intrusions sive–compulsive inventory (ROCI), assessing relationship-centered are perceived as unacceptable and unwanted, and often bring OC symptoms (Doron et al., 2012a), and the partner-related about feelings of guilt and shame regarding their occurrence and/ obsessive–compulsive symptoms inventory (PROCSI), assessing or content. For instance, individuals may feel shame about having partner-focused OC symptoms (Doron et al., 2012b). In accordance critical thoughts about their partner0s intelligence, looks, or social with recent evidence that OCD symptoms are better conceptua- competencies. Guilt and shame may also be associated with lized in terms of dimensions rather than categories (e.g., Haslam, neutralizing behaviors, such as comparing one0s partner with Williams, Kyrios, McKay, & Taylor, 2005; Olatunji, Williams, other potential partners. Haslam, Abramowitz, & Tolin, 2008), we designed the ROCI and

Table 1 Examples of typical triggers, intrusions, appraisals and responses in ROCD.

Typical triggers Intrusion Appraisal Typical responses

Contextual Romantic cues Relationship-centered (e.g., romantic movies, other couples “I do not feel anything” I have to make sure I love her/him Emotional responses interacting etc.) Anxiety Exposure to others with desirable attributes “we are not as happy as they are” Or Guilt (e.g., work colleagues, Facebook etc.) I may be missing the ONE. Shame Physical attraction (or lack thereof) Urge to leave Cognitive-behavioral responses Talk of commitment Partner-focused Reassurance seeking, monitoring feelings, Emotional “She is unattractive” I will regret this forever comparisons avoidance (e.g., romantic cues Boredom and attractive others) Anger “that is a stupid thing to say” (by the Or partner) Anxiety “this woman is interesting”(not I will never be happy with my Apathy partner) partner Jealousy G. Doron et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180 171 the PROCSI to assess relationship-centered and partner-focused we explore the role of OCD related beliefs, processes related to symptoms on a continuum, from mild preoccupation to severe and dysfunctional monitoring of internal states, and perceptions of debilitating disorder. Our references to ROCD symptoms through- relational commitment in the development and maintenance of out this paper correspond to this dimensional view. ROCD. Following recent models of OCD, we then suggest that pre- The ROCI was constructed to measure the severity of obses- existing self-vulnerabilities and attachment insecurities may be sions (i.e., preoccupation and doubts) and compulsions (i.e., implicated in the exacerbation of intrusions into obsessions. Finally, checking and reassurance seeking) on three relational dimensions: we evaluate the potential role of other personality factors, societal one0s feelings towards a relationship partner (e.g., “I continuously influences, and parenting and family environment factors in the reassess whether I really love my partner”), the partner0s feelings etiology and preservation of ROCD symptoms. towards oneself (e.g., “I continuously doubt my partner0s love for me”), and the “rightness” of the relationship (e.g., “I check and 4.1. ROCD and cognitive models of OC-related disorders recheck whether my relationship feels right”). Findings supported this three-factor structure above and beyond two alternative Cognitive behavioral models of OC-related disorders give a central measurement models, but also suggested the existence of role to maladaptive appraisals of internal or external stimuli in the a higher-order general factor for relationship-centered OC symp- development and maintenance of these disorders. According to such toms. The ROCI performed well on most goodness of fit indices, models (e.g., Rachman, 1997; Storch, Abramowitz, & Goodman, 2008; and the total and subscale scores were highly reliable (Doron et al., Wilhelm, Buhlmann, Cook, Greenberg, & Dimaite, 2010; Wihlem & 2012a). Neziroglu, 2002), obsessive preoccupation is a result of catastrophic The PROCSI was designed to measure obsessions (i.e., preoccu- misinterpretations of common phenomena. In the case of OCD, pations and doubts) and neutralizing behaviors (i.e., checking) individuals catastrophically interpret the presence or consequence of focused on the perceived flaws of one0s relationship partner in six naturally occurring intrusive thoughts as indicating imminent danger character domains: physical appearance, sociability, morality, to self or others (Rachman, 1997; Salkovskis, 1985). Similarly, in the emotional stability, intelligence, and competence. Findings for this case of Body Dysmorphic Disorder (BDD), individuals catastrophically measure supported a six-factor structure above and beyond misinterpret the significance and social consequences of esthetic alternative measurement models, but again suggested the exis- features and minor flawsintheirownappearance(e.g.,“people will tence of a higher-order general factor for partner-focused OC be disgusted of me”; Wilhelm et al., 2010; Veale, 2004). symptoms. The PROCSI0s total and subscales scores were found Cognitive beliefs and biases, such as threat overestimation, perfec- to be internally consistent and had good test–retest reliability tionism, intolerance of uncertainty, importance of thoughts and their (Doron et al., 2012b). control, and inflated responsibility increase the likelihood of cata- ROCI and PROCSI scores seem to discriminate between ROCD strophic appraisals in OC-related disorders (OCCWG, 2005; Storch and other OCD symptoms. In an ongoing study, we compared the et al., 2008). These appraisals, in turn, promote selective attention ROCI and PROCSI scores of 17 clients presenting with ROCD to the towards potentially distressing stimuli (OCCWG, 1997; Veal, 2004). scores of 18 clients presenting with other OCD themes. We also Moreover, ineffective strategies for dealing with such stimuli, such as used the Mini International Neuropsychiatric Interview (MINI; repeated checking and reassurance seeking, paradoxically exacerbate Sheehan et al., 1998) to attain clinical diagnosis. Findings so far the frequency and emotional impact of such preoccupations. show significant differences between the two groups on the ROCI, ROCD symptoms may involve cognitive beliefs and biases similar to F(1, 33)¼10.28, p¼.003, ŋ²¼.24, and the PROCSI, F(1, 33)¼5.42, those underlying other OC phenomena (Doron, Szepsenwol, Derby, & p¼.026, ŋ²¼.14. ROCD clients0 mean ROCI scores (on a 0 to 4 scale) Nahaloni, 2012). Some dysfunctional OCD related processes, however, were higher (M¼2.10, SD¼.67) than those of clients presenting maybemorepertinenttotherelationalOCDtheme.Inthefollowing other OCD symptoms (M¼1.16, SD¼1.02). This difference paragraphs, we first describe the way beliefs previously identified as remained significant when controlling for severity of OCD and important in OCD may play a role in ROCD. We then refer to processes depression symptoms. Similarly, ROCD clients0 mean PROCSI that may be specifically germane to ROCD symptoms. scores were higher (M¼1.33, SD¼.56) than clients presenting other OCD symptoms (M¼.78, SD¼.79). Again, this difference 4.2. ROCD and OCD-related maladaptive beliefs remained significant when controlling for severity of OCD and depression symptoms. Thus, ROCD symptoms, as measured by the Beliefs previously linked with OCD have also been found to be ROCI and the PROCSI, seem to be conceptually and empirically linked with ROCD (Doron et al., 2012a, 2012b). OC-related beliefs differentiated from other OCD symptom dimensions. may influence interpretations of intrusive thoughts pertaining to Nevertheless, as the ROCI and PROCSI are designed to assess the relationships or the relationship partner. For instance, over- obsessive–compulsive phenomena, small to moderate correlations estimation of threat may bias individuals0 interpretations of are expected between these measures and tools assessing other others0 feelings towards them (e.g., “He didn0t call for hours, he OCD symptoms. Indeed, we have found moderate correlations doesn0t really love me”) and the severity and consequences of the between the ROCI and the Obsessive Compulsive Inventory- partner0s perceived deficits (e.g., “he is extremely unstable, hence Revised (OCI-R; Foa et al., 2002). Specifically, the ROCI total score he will never be able to provide for our family”). Perfectionist was moderately correlated with the OCI-R total score (r¼.45) and tendencies may promote preoccupation with the “rightness” of the subscale scores (rs ranged from .28 for neutralizing to .47 for relationship (e.g., “I don0t feel perfect with him all the time so obsessions; Doron et al., 2012a). Similarly, small to moderate maybe he is not THE ONE”) and other-oriented perfectionism correlations were found between the PROCSI total score and the (Hewitt & Flett, 1991) may result in extreme preoccupation with OCI-R total score (r¼.44) and subscale scores (rs ranged from .28 specific features of a romantic partner0s personality or appearance for ordering to .40 for obsessions; Doron et al., 2012b). (e.g., “she is not moral enough”, “her nose is too big”). The belief that one can and should control one0s thoughts may promote suppression efforts of relationship doubts or negative thoughts 4. Development and maintenance mechanisms in ROCD about the partner, thereby increasing their occurrence. Intolerance for uncertainty may play a particularly important The etiology and maintenance of ROCD symptoms is most likely role in ROCD as it pertains to one of its core elements – uncertainty multi-faceted and involving a combination of factors. In this section, about being in the right relationship. Moreover, ROCD symptoms 172 G. Doron et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180 often concern vague, intangible internal states (e.g., love) that These may include beliefs focusing on the disastrous consequences inherently involve uncertainty. Difficulty with uncertainty may of leaving a relationship (e.g., “If I leave, I will hurt my partner”) increase distress and maladaptive management of commonly and the catastrophic consequences of remaining in a less than occurring relationship doubts. We believe that effective treatment perfect relationship (e.g., “If I maintain a relationship I am not sure requires postponing of any relational decisions at the initial stages about, I will be miserable forever”). of therapy, making such tolerance an important target for treat- In this context, research on relational commitment may be ment interventions (see Section 8). particularly relevant. Adams and Jones (1997) proposed a three- dimensional conceptualization of relational commitment, includ- 4.3. ROCD and monitoring of internal states ing (a) a personal commitment dimension (feelings of affection, intimacy, and love toward a partner); (b) a moral-normative Liberman and Dar (2009) have recently proposed an innovative dimension (one0s moral obligation to the relationship and the model of OCD. They suggested that individuals with OCD doubt partner); and (c) a constraining dimension (social, financial and their internal states and show decreased capacity to access these emotional negative costs of relationship dissolution). Studies have states. In an attempt to decrease doubts regarding their inner found that high levels of personal commitment help romantically feelings and states, OCD clients over-monitor and tend to rely on involved people to appreciate the good qualities of a partner and external feedback for assessing them. In support of these hypoth- shield them from the temptation of attractive alternatives (see eses, studies have found that, as compared to participants with Lydon, 2010 for a review). In the case of clients with ROCD, low low obsessive–compulsive tendencies, participants with high levels of personal commitment may intensify obsessional doubts obsessive–compulsive tendencies are (a) less accurate in assessing concerning the rightness of their relationship and the attractive- internal states, such as their own level of relaxation or muscle ness of their partner. Moreover, these doubts may further reduce tension, and (b) rely more on external feedback in assessing these personal commitment, which, in turn, may decrease the effective- internal states (Lazarov, Dar, Oded, & Liberman, 2010, Lazarov, Dar, ness of temptation-shielding mechanisms and then intensify the Liberman, & Oded, 2012). Moreover, Shapira, Gundar-Goshen, severity of ROCD symptoms. Liberman, and Dar (2013) have recently found that intense The normative and constraining dimensions of relational com- monitoring of one0s feelings of emotional closeness in an intimate mitment may be heavily influenced by one0s culture and religion conversation hampers achieving these feelings, as measured by (e.g., Adams & Jones, 1997; Allgood, Harris, Skogrand, & Lee, 2008; sitting distance between pair members. Increased monitoring may also see Section 4.7). In our view, these two dimensions reflect the indeed reduce access to internal states and feelings. presence of catastrophic negative beliefs regarding the moral (e.g., Relationship-centered OC symptoms, by definition, involve “If I leave her I will be an immoral person”) and practical (e.g., preoccupation with internal states (e.g., love for a partner or “I will have to move out of my home”, “I will be excommunicated feeling right). In order to assess or reduce uncertainty regarding by my church”) consequences of relationship termination that may their own feelings, ROCD clients often invest time and effort in exacerbate ROCD symptoms. Indeed, it is not uncommon for monitoring their feelings and emotions. We often hear clients clients with ROCD to express strong commitment-related moral describe continuous monitoring of their feelings towards their beliefs (e.g., “you should only marry once”). Such beliefs seem to partner (e.g., “Do I feel love right now?”; “Does this feel right?”). amplify the need for certainty about the relationship or the In such instances, monitoring of internal states is used as a partner, thereby increasing ROCD clients0 tendency to use neutra- deliberate attempt to reassure oneself about the strength and lizing behaviors (e.g., monitoring of internal states, monitoring of quality of one0s own feelings. partner0s behaviors). Similarly, focusing on the social, emotional ROCD clients also describe using what they perceive as “objec- and financial negative consequences of relationship dissolution tive” signs in order to judge their feelings. For instance, one client may magnify fears of making the “wrong decision”, leading to quantified her partner0s love for her by compulsively comparing catastrophic interpretations of relational doubts and even the time he spent with her to the time he spent with others (e.g., encouraging avoidance of relationships all together. his mother). Another client reported ‘time spent crying0 following An additional relationship-related factor that may be involved a relationship breakup as a retrospective indicator of his feelings. in the maintenance of ROCD symptoms is anticipated regret. More often, however, clients gage relationship quality or rightness Regret is experienced when we realize that our current situation by referring to the cognitive (e.g., doubts and preoccupations) and could have been more satisfying had we made a different choice. behavioral (e.g., looking at other women) features of ROCD Anticipated regret refers to regret that we anticipate experiencing symptoms. For instance, clients may identify experiencing doubts in the future (Zeelenberg, 1999). Fear of anticipated regret may as a negative indicator of relationship “rightness” or of their significantly heighten reactivity to relational intrusions. For feelings towards their partner. Accordingly, clients may treat instance, one of our clients expressing strong fears of anticipated thoughts about partner0sdeficiencies as negative indicators of regret described an “extremely distressing situation”: While on their own feelings (e.g., “if I see so many flaws, I do not love him”; Facebook, the thought that his partner is not intelligent enough see below for further discussion of this link). “popped” into his head. He reported the following thought Increased monitoring of internal states and referring to exter- sequence: “There are so many women out there, if I stay with nal feedback for the evaluation of such states may alleviate distress one that may not be smart enough I will regret it forever, but if in the short term. Like other compulsive behaviors, however, I leave, I may realize that I missed the love of my life”. Indeed, one repetitive use of such strategies results in ROCD symptoms0 core feature of ROCD is extreme fear of making the wrong exacerbation. relationship-related decision. Clients alternate between being terrorized by thoughts of separation (e.g., “I will always think that 4.4. ROCD and relationship-related beliefs I may have missed THE ONE”) and being trapped in the wrong relationship (e.g., “I will always feel that I have compromised”). Recently, Doron et al. (2012a) proposed that maladaptive relational beliefs can uniquely contribute to the development 4.5. ROCD and self-related processes and maintenance of ROCD. Following Rachman0s model (1997, 1998), they suggested several biases implying catastrophic con- Pre-existing self-vulnerabilities may also play a significant role sequences of relationship-related thoughts, images, and urges. in the development and maintenance of ROCD. Rachman (1997, G. Doron et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180 173

1998) has argued that intrusions challenging a person0s system of Research has supported a two-dimensional representation of values are more likely to escalate into obsessions than intrusions individual differences in attachment insecurities in adulthood, not challenging such values. Following this idea, several scholars organized around two orthogonal dimensions of anxiety and have proposed that pre-existing self-vulnerabilities contribute to avoidance (Brennan, Clark, & Shaver, 1998; Mikulincer & Shaver, the specific theme of an individual0s obsession (e.g., Aardema & 2007). Attachment anxiety involves worries regarding the avail- O0Connor, 2007; Aardema, Molding, Radomsky, Doron, & Allamby, ability of significant others to adequately respond in times of need, in press; Bhar & Kyrios, 2007; Clark & Purdon, 1993; García- and the adoption of “hyperactivating” attachment strategies (i.e., Soriano, Clark, Belloch, del Palacio, & Castañeiras, 2012). In this energetic, insistent attempts to obtain care, support, and love from context, Doron and Kyrios (2005) have argued that thoughts or attachment figures) as a means of regulating distress. Attachment events that challenge highly valued self-domains (e.g., moral self- avoidance involves distrust in significant others and a striving to domain) may threaten a person0s sense of self-worth in this maintain autonomy and emotional distance from them. Avoidantly domain, and activate cognitions and behavioral tendencies aimed attached individuals commonly endorse “deactivating” strategies, at counteracting the damage and compensating for the perceived such as denial of attachment needs and suppression of deficits (e.g., Doron, Sar-El, & Mikulincer, 2012). For some indivi- attachment-related thoughts and emotions. Individuals who score duals, such as OCD sufferers, these responses paradoxically low on both insecurity dimensions are said to hold a stable sense increase the accessibility of negative self-cognitions (e.g., “I0m of attachment security (Mikulincer & Shaver, 2007). immoral and unworthy”) that together with the activation of other Attachment insecurities may hinder adaptive coping with self- dysfunctional beliefs associated with obsessions (e.g., inflated related challenges by activating dysfunctional distress-regulating responsibility, threat overestimation; OCCWG, 1997) can result in strategies, further exacerbating anxiety and ineffective responses the development of OCD. (Doron et al., 2009). For instance, anxiously attached individuals In our view, vulnerability in the relational self-domain may tend to react to self-relevant failures by amplifying the negative lead to the escalation of relationship-centered intrusions into consequences of the aversive experience, ruminating on it, and obsession (Doron et al., 2013). That is, sensitivity to intrusions increasing mental activation of attachment-relevant fears such as challenging self-perceptions in the relationship domain (e.g., “Ido fear of being abandoned because of one0s “bad” self (Mikulincer & not feel right with my partner at the moment”) may trigger Shaver, 2003). Thus, in addition to disrupting functional coping catastrophic relationship appraisals (e.g., “being in a relationship with experiences that challenge sensitive self-domains, anxiously I am not sure about will make me miserable forever”) and other attached people0s coping strategies may render them particularly maladaptive appraisals (e.g., “I shouldn0t have such doubts regard- vulnerable to relationship-centered obsessions. ing my partner”), followed by neutralizing behaviors (e.g., con- Recent findings clearly indicate that self-sensitivity in the rela- stantly seeking reassurance that the relationship is going right). tional domain and attachment anxiety jointly contribute (i.e., Similarly, when one0s self-worth is contingent on the perceived double-relationship vulnerability) to the development and main- value of a relationship partner (i.e., partner-contingent self-worth), tenance of ROCD symptoms (Doron et al., 2013). In one study, every thought or event related to this partner0s flaws can intensify attachment anxiety was linked with more severe ROCD symptoms partner-focused OC symptoms. Hence, individuals perceiving their mainly among individuals whose self-worth was strongly depen- partner0s failures or flaws as reflecting on their own self-worth are dent on their relationship. In a second study, subtle hints of expected to be more sensitive to thoughts or events pertaining to incompetence in the relational self-domain (i.e., mildly negative their partner0s qualities and characteristics. Such intrusions may feedback regarding the capacity to maintain long-term intimate- trigger catastrophic appraisals (e.g., “He is not intelligent enough. relationships) led to increased ROCD tendencies mainly among We will never be able to support our family”) and neutralizing individuals high in both attachment anxiety and relationship- behaviors (e.g., increased monitoring of the partner0s grammatical contingent self-worth. Thus, jointly with sensitivity in the relational errors). self-domain, attachment anxiety may result in increased suscept- Although relational challenges and doubts of the kinds ibility to relationship-related obsessive doubts and worries. described above are fairly frequent, most individuals manage to adaptively respond to such self-challenges and are therefore less 4.7. ROCD and other personality and societal factors likely to be flooded by negative self-evaluations following them. One psychological mechanism suggested to thwart such adaptive Personal factors may interact with societal influences to affect regulatory processes is attachment insecurity (Doron, Moulding, one0s ability to feel secure with one0s choice of partner. In recent Kyrios, Nedeljkovic, & Mikulincer, 2009). years, we have seen a significant increase in exposure to other people, their behaviors, and their personal lives. Such increased 4.6. ROCD and attachment representations exposure is particularly evident in digital social networks (e.g., Facebook, Googleþ) and dating websites/applications, thus creat- In his seminal work, Bowlby (1973,1982) proposed that inter- ing an illusion of availability. Many clients with ROCD describe such personal interactions with primary caregivers (“attachment extensive exposure to “potential” partners as a powerful trigger of figures”) early in life are internalized in the form of mental their relationship doubts and preoccupations. In this context, it is representations of self and others (“internal working models”). import to note that religious views, cultural norms and socio- When attachment figures are absent, inconsistently available, or economic status may significantly impact both actual (e.g., ability rejecting in times of need, one0s sense of attachment security to work outside the family home or acceptability of divorce) and (a sense that the world is generally a safe place, others are helpful perceived availability of alternative partners (e.g., having access to when called upon, and it is possible to explore the environment social media). curiously and confidently and engage rewardingly with other Studies in behavioral economics have long supported the role of people) is undermined and negative models of self and others perceived availability of better options in indecisiveness and differing are developed. Such models increase the likelihood of self-related choices (e.g., Tversky & Shafir, 1992). Within the relationship setting, doubts and emotional difficulties later in life (Mikulincer & Shaver, recent studies looking at decision making in online dating sites show 2007). Parents are most frequently the main attachment figures that more search options (i.e., increased perceived availability) result in during childhood. In adulthood, however, romantic partners often excessive searching, poorer decision making and reduced selectivity in take parents0 place as main attachment figures. finding potential partners (the “more-means-worse effect”; Wu & 174 G. Doron et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180

Chiou, 2009). More recently, Yang and Chiou (2010) examined the 5.1. ROCD and relationship satisfaction moderating effect of personality tendencies on decision making in the context of choice proliferation. Findings indicated that the more- ROCD symptoms may be particularly detrimental to intimate means-worse effect is accentuated among individuals with “maximiz- relationships. Similar to common OCD symptoms, ROCD symp- ing” decision making tendencies. Maximizing strategies are aimed at toms may bring about negative responses from the relationship achieving the best possible option and require an exhaustive search of partner and be a source of relationship conflict. This may be even all possibilities (Simon, 1956; Schwartz et al., 2002). In contrary, more prominent in ROCD, because the focus of the preoccupation “satisfying” strategies strive for a “good enough” choice, searching is the relationship itself or the relationship partner. Constant until meeting an acceptable option. Indeed, individual differences in relational conflict may seriously undermine relationship satisfac- maximizing decision-making strategies were linked with poorer tion and endanger the relationship0s stability (Amato, 2000). mental health (e.g., depression symptoms), increased maladaptive Yet, ROCD symptoms may impact relationship satisfaction in beliefs (e.g., perfectionism), more regret, and higher likelihood of additional ways. Repeatedly doubting one0s relationship or rela- engaging in upward social comparisons (Schwartz et al., 2002). tionship partner may seriously undermine core relationship pro- Maximizers were also found to spend more time reviewing options cesses and directly destabilize the relationship. For instance, when making a choice than do satisfiers, arguably increasing max- positive ideals about one0s relationship and romantic partner were imizers0 uncertainty regarding the best choice (Dar-Nimrod, Rawn, identified as beneficial cognitive biases of individuals in successful Lehman,&Schwartz,2009;Iyengar,Wells,&Schwartz,2006). More- romantic relationships (e.g., Fletcher, Simpson, & Thomas, 2000; over, recent findings suggest that maximizers tend to avoid commit- Overall, Fletcher, & Simpson, 2006). Idealized relationship and ment to their decisions in a way that contributes to reduced partner perceptions have been linked to positive relational out- satisfaction (Sparks,Ehrlinger,&Eibach,2012). Thus, increased per- comes,such as greater satisfaction, less conflict, and more stable ceived availability of alternatives together with a maximizing decision relationships (e.g., Barelds & Dijkstra, 2011; Murray et al., 2011; making strategy may increase doubts regarding one0srelational Murray, Holmes, & Griffin, 1996; Rusbult, Van Lange, Wildschut, choices. Yovetich, & Verette, 2000), whereas the fading of such idealized perceptions has been linked to relationship breakup (Caughlin & 4.8. ROCD, parenting, and family environment Huston, 2006). Individuals with ROCD are likely to find it difficult to maintain idealized relationship and partner perceptions, or Parents are arguably the first and most dominant model of even positive ones, in the face of repeated intrusions, and are romantic relationships a person is exposed to during childhood. hence more likely to experience poor relationship satisfaction. It is reasonable to hypothesize, therefore, that the quality of a Two studies conducted in nonclinical samples have found the person0s parents0 romantic relationship would impact her or his expected relationship between ROCD symptoms and poor rela- relational beliefs, emotions, and behaviors. Indeed, early experi- tionship satisfaction. In one study, relationship-centered OC symp- ences, particularly parental conflict, have been theoretically and toms, as measured by the ROCI, were significantly associated with empirically linked with people0s relational attitudes, values and relationship dissatisfaction, even when controlling for common behaviors (See Amato, 2000, for review). Moreover, parental OCD symptoms, mood symptoms, low self-esteem, attachment conflict has been theoretically and empirically associated with anxiety and avoidance, and relationship ambivalence (Doron et al., other ROCD-related factors, such as attachment insecurities, 2012a). This finding was replicated in a subsequent study with dysfunctional self-views, and mental health problems (e.g., similar controls (Doron et al., 2012b). Partner-focused OC symp- Amato, 2001; Davies & Cummings, 1994; Jekielek, 1998; toms, as measured by the PROCSI, were also found to be sig- Mikulincer & Shaver, 2007). Finally, many clients with ROCD recall nificantly associated with relationship dissatisfaction, even when a longstanding history of intense and overt parental conflict. Thus, controlling for relationship-centered symptoms in addition to all we propose that a negative family environment during childhood, the other controls mentioned above. In fact, both partner-focused particularly comprising of intense and longstanding parental and relationship-centered OC symptoms had their own unique conflict, can be a distal vulnerability factor of ROCD. statistical contribution to relationship dissatisfaction, suggesting somewhat divergent causal paths (Doron et al., 2012b). It should be noted, however, that the relationship between relationship 5. Relational and personal consequences of ROCD satisfaction and ROCD is likely to be bidirectional. That is, poor relationship satisfaction rooted in other factors may promote Research has shown that OCD can carry negative consequences relationship-centered and partner-focused doubts, just like endo- for relational functioning (e.g., Angst et al., 2004). For example, the genous relationship-centered and partner-focused doubts may continuous pressure that people with OCD exert on their relation- promote poor relationship satisfaction. ship partners to participate in compulsive rituals has been found to be a source of relational tension and conflict and to impair relationship quality (Koran, 2000). Accordingly, partner0s accom- 5.2. ROCD and well-being modation to OCD symptoms (e.g., taking part in rituals or in avoidance of anxiety-provoking situations) has also been linked ROCD symptoms may lead to extreme distress, anxiety, and with symptom severity, treatment outcomes, and lower relation- disability. Clients frequently report feelings of shame and guilt ship satisfaction of the individual with OCD (Boeding et al., 2013). about their doubts and preoccupations. These feelings encourage Furthermore, OCD severity has been associated with decreased self-criticism and may lower psychological well-being. In addition, family, work, and social functioning (Ruscio, Stein, Chiu, & Kessler, neutralizing behaviors involved in ROCD are experienced as 2008), higher caregiver burden and distress (Ramos‐Cerqueira, uncontrollable and irrational, thereby promoting negative self- Torres, Torresan, Negreiros, & Vitorino, 2008; Vikas, Avasthi, & perceptions. The time and energy dedicated to preoccupations Sharan, 2011) and increased marital distress (Emmelkamp, De with a relationship often comes at the expense of work and Haan, & Hoogduin 1990; Rasmussen & Eisen, 1992; Riggs, Hiss, & academic functioning. Indeed, individuals with ROCD report dis- Foa, 1992). Only recently, research has begun to explore the tress due to their symptoms, the related disability stemming for contribution of ROCD symptoms to poor relational and personal these symptoms, and the anguish they believe they are causing outcomes. close others. G. Doron et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180 175

Recent findings from studies conducted in non-clinical samples feelings towards this partner or the relationship. In this way, support such client reports. In one study, relationship-centered OC clients “justify” their doubts and worries by referring to their symptoms, as measured by the ROCI, were significantly associated partner0s “objective” flaws. with depression, even when controlling for common OCD symp- toms, relationship ambivalence, attachment anxiety and avoid- 6.2. Between-person infiltration of ROCD symptoms ance, and low self-esteem (Doron et al., 2012a). This finding was replicated in a subsequent study, in which anxiety and stress were In addition to being self-enhanced within the same person over statistically controlled in addition to self-esteem and common time, ROCD symptoms may also spread from one person to the OCD symptoms (Doron et al., 2012b). Doron et al. (2012b) also next, especially within romantic relationships. That is, a person0s found that partner-focused OC symptoms, as measured by the ROCD symptoms may “infect” over time his or her relationship PROCSI, were significantly associated with depression, even when partner, leading to more ROCD symptoms among this partner. For relationship-centered OC symptoms were added to all the above- instance, during a couples-therapy session, a woman described her mentioned controls. In fact, partner-focused OC symptoms were partner0s repeated questioning of her feelings towards him as a found to be more consequential to depression than relationship- trigger for such doubts. Initial findings from an ongoing long- centered OC symptoms. Whereas partner-focused symptoms itudinal study of dating partners indicate that within a one-month predicted depression over and above relationship-centered symp- period, relationship-centered symptoms in one dyad member toms, the opposite was not true. increased relationship-centered symptoms in the other dyad member. At the same time, partner-focused symptoms in one dyad member increase partner-focused symptoms in the other 6. The association between relationship-centered and partner- dyad member. focused OC symptoms These dyadic effects may result from several ROCD-related processes. For example, having one partner constantly question ROCD can involve relationship-centered and partner-focused the relationship may cause the other partner to do the same (e.g., symptoms. In the following section, we explore the reciprocal “He0s unsure about this relationship. Am I sure about it?”). ROCD associations between these two presentations of ROCD phenomena. symptoms such as repeated reassurance seeking (e.g., “Do you love We begin by discussing the within-person interplay between me?”) may lead to an increase in partners0 monitoring of their own relationship-centered and partner-focused symptoms. We then internal states (i.e., “do I feel love towards him?”) in response to consider the impact of ROCD symptoms on the relationship partner. repeated questioning. Similarly, compulsive comparisons of one partner may increase the likelihood of the other partner doing the 6.1. Within-person bidirectional infiltration of ROCD symptoms same (e.g., “she keeps comparing me to her former boyfriend, but how does she compare to my former girlfriend?”). More generally, Clinical experience and empirical findings indicate that however, the emotional burden laid by one partner constantly relationship-centered and partner-focused OC symptoms often questioning the other partner0s character, appearance, or suitabil- co-occur. Indeed, the total scores of the PROCSI and ROCI were ity may lead to increased personal stress and higher threat found to be strongly correlated (e.g., Doron et al., 2012b). Two appraisals in the targeted partner, which, in turn, may lead to recent longitudinal studies suggest that these two presentations of more ROCD symptoms in this partner. Finally, one partner0s ROCD symptoms may fuel each other over time. In one long- continuous doubting of the relationship may activate preexisting itudinal study, partner-focused OC symptoms predicted an attachment insecurities in the other partner, thereby contributing increase in relationship-centered OC symptoms two months later to the development of ROCD symptoms in this partner. and vice versa (Doron et al., 2012b). More recently, these findings were replicated in a one-year longitudinal study (Szepsenwol, Doron, & Shahar, submitted for publication). 7. ROCD and related constructs Partner-focused OC symptoms may exacerbate relationship- centered OC symptoms by increasing doubts regarding the rela- We have argued that ROCD involves features that are unique to tionship and the relationship quality. As discussed earlier, relation- the relational domain as well as features that are common with ship satisfaction is hampered by partner-focused OC symptoms other OCD symptoms. Yet, if ROCD is to be understood as a distinct (Doron et al., 2012b). ROCD clients tend to interpret the occurrence phenomenon, it is essential to differentiate it from other related of intrusions regarding the partner0s flaws as evidence that some- constructs. In this section, we review the conceptual and empirical thing is wrong in this relationship. In this way, preoccupations links between relationship-centered OC symptoms and related with the partner0s perceived flaws may increase the likelihood of constructs, such as worry and social anxiety. We also deal with the developing doubts regarding the relationship “rightness” and potential links between partner-focused OC phenomena and body- one0s feelings towards the partner. Clinical experience also shows dysmorphic symptoms. that ROCD clients with partner-focused symptoms often devote increased attention to romantic alternatives and compulsively 7.1. Relationship-centered OC symptoms and worries compare their current romantic partners to these alternatives. Increased attention to alternatives, when coupled with low rela- Traditionally, relationships are considered to fall within the tionship satisfaction, is likely to lower relationship commitment realm of general worries (Clark, 2004). It is important, therefore, to (Rusbult, 1980) and foster relationship doubts. differentiate between relationship-centered OC phenomena and Relationship-centered OC symptoms may promote partner- worry. Clinical experience and initial empirical findings suggest focused OC symptoms when identifying partner0sdeficiencies is that relationship-centered obsessions can be differentiated from used as a means for assessing the rightness of the relationship or general worries in both content and form. Relationship-centered one0s feelings towards the partner. As argued above, relationship- obsessions, by definition, focus on one0s current feelings towards centered OC symptoms increase monitoring of internal states and a partner, a partner0s feelings towards oneself, and the rightness of reliance on external “objective” feedback for evaluating one0s own a current or past relationship. In contrast, worry often relates to feelings (Liberman & Dar, 2009). For some clients, identification of future consequences of real situations (Clark, 2004; e.g., “what will deficiencies in a partner is used as a proxy for assessing one0s own I do if I break up with my girlfriend?”). Like other forms of 176 G. Doron et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180 obsessions, relationship-centered obsessions are experienced as deficits or flaws. Like in body dysmorphic disorder (BDD), partner- more unwanted, intrusive, and unacceptable than normal worries focused OC symptoms may focus on physical appearance. BDD, and appear to be more strongly resisted. Clients often describe however, is defined by excessive preoccupation with one0sown, thoughts, questions, and doubts “springing up into their mind”. rather than others0 perceived physical flaws. Furthermore, although These intrusions are perceived as exaggerated, having slight or no partner-focused OC symptoms may relate to the partner0s physical realistic basis, and as contradicting a person0s strong feelings features (also termed BDD by Proxy, see Josephson & Hollander, towards a partner. Relationship-centered obsessions are therefore 1997; Greenberg et al., 2013), they often relate to other character- less self-congruent, more likely to be associated with neutralizing istics, such as social qualities (e.g., sociability) or personality efforts, and are perceived as less rational than worries. Further- attributes (e.g., morality). Finally, like other ROCD symptoms, more, whereas worries commonly appear in verbal format, partner-focused obsessive symptoms may occur in a variety of close relationship-centered obsessions come in a variety of forms, relationships (parent–child; person-God etc.). including images, thoughts and urges. Nonetheless, both BDD and partner-focused symptoms involve There is initial empirical evidence supporting the differentiation hypervigilance to perceived defects or flaws and catastrophic between relationship-centered obsessions and general worries. In a interpretations of the consequences of such flaws. Esthetic sensi- recent study, Doron et al. (2013) showed only a small correlation tivity may also be common to both disorders (Lambrou, Veale, & (r¼.21) between the ROCI and one of the most commonly used Wilson, 2011). Therefore, moderate correlations between BDD and measures of general worry – the Penn State Worry Questionnaire partner-focused OC symptoms should be expected. Consistent (PSWQ; Meyer, Miller, Metzger, & Borkovec 1990). with these expectations, Doron et al. (2012b) have found a moderate correlation between BDD symptoms and the PROCSI 7.2. Relationship-centered OC symptoms and social anxiety total score (r¼.39). Furthermore, besides the ROCI score, BDD symptoms were the only significant predictor of changes in Both relationship-centered obsessions and social anxiety may PROCSI scores in a one month follow-up analysis. Importantly, relate to individuals0 close relationships and affect interpersonal BDD symptoms did not show a stronger correlation with the interactions. However, whereas relationship-centered obsessions PROCSI appearance subscale (r¼.32) than with the other PROCSI concern a person0s relational appraisals, feelings, and experiences, subscales, supporting a more generalized underlying common social anxiety concern a person0s perceived functioning in inter- predisposition (Doron et al., 2012b). personal situations. For instance, a person with relationship- centered obsession is likely to be preoccupied with his/her own 7.5. Relationship-related obsessions and sexual orientation feelings towards a partner during or following a romantic encoun- obsessions (HOCD) ter. In contrast, a person with social anxiety is more likely to fear his/her perceived incompetence in a future romantic encounter For some individuals, relational doubts may be strongly linked (i.e., anticipated anxiety), during the romantic encounter (am with sexual orientation obsessions (i.e., doubt about one0s sexual I sweating?) or following the romantic encounter (how did orientation or fears of becoming homosexual; e.g., Williams & I look? Did I blush?). Social anxiety symptoms are more likely to Farris, 2011; Moulding, Aardema, & O0connor, this issue). For include physical symptoms (e.g., blushing and sweating) than instance, one client described the transformation of his ROCD relationship-centered OC symptoms and tend to be associated symptoms to sexual orientation obsession as follows: “It started with more self-congruent negative self-talk. Indeed, in a yet with doubts about the relationship. I continuously asked myself unpublished study with a community cohort (N¼218), the ROCI whether I am in the right relationship. I would check and recheck showed only a small correlation (r¼.22) with social anxiety whether I am attracted to her. After a while, I started thinking symptoms, as measured by the Social Interaction Anxiety Scale maybe it is not about her. Maybe I0m not attracted to women. Since (SIAS; Mattick & Clarke, 1998). then, I can0t stop checking whether I0m aroused by woman and/or men and I really fear finding out I0m homosexual”. A different 7.3. Relationship-centered OC symptoms and obsessional jealousy client describe her HOCD symptoms leading to ROCD symptoms: “I started having obsessions about my sexual preference as an Relationship-centered obsessions and obsessional jealousy may adolescent. As I grew older they abated. Now, however, when I am relate to romantic relationships. Obsessional jealousy, however, in a serious relationship, I continuously doubt my feelings for my focuses on one0s partner alleged unfaithful behaviors and infidelity, partner and whether I am in the right relationship. Maybe I0m rather than the relationship experience. Unlike obsessive jealousy, lesbian and I0m misleading him and myself”. relationship-centered obsessions do not assume the existence of a Preoccupations in ROCD center on the relationship experience. potential rival and are less likely to involve monitoring and checking HOCD involves fears centering on the self. As seen above, of partner0s behaviors for cues of infidelity. increased monitoring of internal states may play a crucial role in Nevertheless, increased ROCD symptoms (e.g., doubts regard- the relationship between ROCD and HOCD. Monitoring of internal ing the partner0s love) may be associated with more obsessional states such as physical attraction and sexual desire may make such jealousy symptoms (e.g., I have to check whether he loves me and states less accessible thereby fueling relational and self-related not someone else). Moreover, ROCD and obsessional jealousy may doubts. Future research may shade further light on this link and its share some vulnerability and maintenance factors such as self- therapeutic implications. sensitivity in the relational domain. Consistent with this, unpub- lished correlational data (n¼218) showed a moderate correlation (r¼.41) between the ROCI and jealousy driven checking behaviors, 8. Assessment and treatment as measured by the checking subscale of the questionnaire of affective relationships (QAR; Marazziti et al., 2003). Worrying, having doubts or even being preoccupied with a particular relationship does not automatically suggest a diag- 7.4. Partner-focused OC symptoms and BDD nosis of ROCD. Like other OCD symptoms, relationship-related OC symptoms require psychological intervention only when they are Partner-focused OC symptoms are defined by marked preoccu- causing significant distress and are incapacitating. Diagnosing pation and neutralizing behavior concerning perceived partner0s ROCD is further complicated by the fact that such experiences, G. Doron et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180 177 even if distressing, may still be a part of the normal course of a still frequency and duration, the expected feared outcome or worry developing relationship, mainly during the flirting and dating about the obsessions, and the responses to these intrusions. stages, or reflect real life problems. Furthermore, treatment is Responses include emotions (e.g., anxiety, guilt), overt compul- frequently sought only during relational instability (e.g., increasing sions (e.g., checking, comparing, reassurance seeking), covert pressure from a partner, low relationship satisfaction) and ROCD is compulsions (e.g., thought suppression, monitoring of internal often comorbid with other disorders, such as depression, other states, self-reassurance), and avoidance or safety behaviors. anxiety disorders, and other OCD symptoms. Establishing that a person is suffering from ROCD; therefore, requires particular care. 8.2. Pharmacotherapy

There are no known studies as to the effectiveness of pharma- 8.1. Assessment cotherapy to ROCD symptoms. Our clinical experience shows, however, that high doses of SSRIs as accepted in the treatment Relational obsessions usually begin in the early stages of a of OCD (e.g., Montgomery, Kasper, Stein, Hedegaard, & Lemming, relationship and exacerbate as the relationship progresses or reach 2001) may lead to a reduction of ROCD symptoms for some decision points (e.g., cohabitation, marriage). Clinicians should individuals. keep in mind that relationship obsessions exist and persist regardless of relationship conflict. When suspecting ROCD, initial evaluation should include a clinical interview to ascertain the 8.3. Psychosocial treatments diagnosis of OCD and coexisting disorders or medical conditions. It is strongly recommended to use structured interviews, such as The effectiveness of psychosocial treatment for ROCD has yet to the Mini International Neuropsychiatric Interview (MINI; Sheehan be tested. A successful therapeutic intervention, however, should be et al., 1998) or the SCID (First, Spitzer, Gibbon, & Williams, 1997), to based on a theoretical understanding of the vulnerability factors ascertain disability and diagnosis of OCD. Additional instruments and maintenance processes described above. We are currently should be used to quantify ROCD symptom severity (e.g., the ROCI developing a treatment manual that will address the maintaining and the PROCSI), other OCD symptoms (e.g., OCI-R, Yale Brown processes and vulnerability factors of ROCD. Following current Obsessive Compulsive Scale), OCD-related cognitions (e.g., Obses- cognitive behavioral interventions for OCD, we believe such treat- sive Beliefs Questionnaire; Molding et al., 2011), depression, ment should include assessment and information gathering, anxiety, and Body Dysmorphic symptoms. psycho-education and identification and challenging of dysfunc- A thorough history would include the presenting problem(s), tional thinking patterns, self-perceptions, and attachment-related background of the problem(s), and personal history with specific fears and defenses. Exposure Response Prevention (ERP) and other emphasis on relational history, family history and environment behavioral experiments are believed to be very useful in this and current relationship assessment. It is of outmost importance therapeutic process. to gain a clear understanding of the nature, pattern, and duration Psycho-education sets the tone for the rest of therapy. The of clients0 symptoms within the current relationship context and psycho-education component should cover the cognitive model of in previous relationships. Level, frequency and themes of current OCD and ROCD (see Fig. 1). It is important to provide the client relational conflict, strategies of resolving such conflicts, sexual with the rationale for the therapeutic process and discuss the functioning and satisfaction as well as perceptions of commitment course of therapy. The influence of ROCD symptoms on decision and relationship expectations should be noted. Therapists should making should then be addressed and the difference between collect detailed information about triggers of obsessions, their obsessive thinking and problem solving clarified. In this context,

Fig. 1. The ROCD maintenance cycle. 178 G. Doron et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 169–180 the impact of ROCD symptoms on one0s ability to experience 9. Summary feelings should be explored. Based on these understandings, it is best to reach an agreement to postpone decisions regarding the OCD is a debilitating disorder with a wide array of obsessional relationship until ROCD symptoms are significantly reduced. themes. While some OCD themes have been the subject of intense Contingent on the client0s approval, one should consider invol- investigations leading to significant theoretical and clinical ving the partner in the therapeutic process. In such cases, partner0s advancements, research on relationship-related obsessive–com- symptom accommodation should be assessed, ROCD psycho- pulsive phenomena has only recently begun. In this paper, we education provided, and strategies for reducing dyadic influences presented relationship obsessive–compulsive disorder (ROCD), suggested. defined its main features, and described its phenomenology. Monitoring of obsessions and compulsions should assist the Measures of ROCD symptom severity were presented and their client and the therapist to manage the reduction of compulsions associations with other OCD themes discussed. and avoidance behaviors. The cognitive component of ROCD Drawing on recent cognitive-behavioral models of OCD, social treatment may include identification and challenging of OCD- psychology and attachment research, we discussed the role of related maladaptive beliefs (e.g., importance of thoughts, intoler- OCD-related beliefs, processes related to dysfunctional monitoring ance for uncertainty). It is also important to challenge catastrophic of internal states, and perceptions of relational commitment in the beliefs about relationships (e.g., “If I stay in a relationship I am not development and maintenance of ROCD. We then implicated pre- sure about, I will always be miserable”; “If I commit to this existing self-vulnerabilities and attachment insecurities in the relationship, I will never be able to get out of it” or “if I leave this exacerbation of common relationship worries into obsessions relationship, I will always regret it”). In this context, ERP tasks and evaluated the potential role of personality factors, societal such as scripts related to fear of regret (e.g., finding yourself influences, parenting, and family environments in the etiology and miserable with your partner in a few years and/or finding yourself maintenance of ROCD symptoms. The relational and personal miserable without the same partner), other feared scenarios (e.g., impact of ROCD symptoms and the reciprocal associations weddings) and in vivo exposure to “triggering” sites or movies between relationship-centered and partner-focused OC symptoms (e.g., romantic comedies) may be useful. Many clients with ROCD were also discussed. Finally, we reviewed the conceptual and describe fears of reenacting their parental relationship. When empirical links between ROCD symptoms and related constructs applicable, this information should be integrated in to the expo- and suggested theoretically driven assessment and interventions sure scripts. An effective intervention may also address the mean- procedures. ing and consequences of increased monitoring of internal states. Although consistent with our theoretical model, this new body Suitable behavioral experiments for exemplifying the effects of of research has several limitations. Many of the proposed factors excess monitoring may include in-session repetitive monitoring of hypothesized to be involved in ROCD are yet to be empirically internal states (e.g., feelings of “closeness” to the therapist). evaluated. Furthermore, many studies have been conducted with Contingencies of self-worth on particular relational aspects non-clinical samples. Although non-clinical individuals experience (e.g., relationships, partner value) should be explicitly explored, OCD-related beliefs and symptoms, they may differ from clinical such that the client understands the association between distress patients in the type and severity of symptoms and the resulting and perceived failure in these relational aspects. Effort should be degree of impairment. Future ROCD research should include given to identifying and expanding the rules of competence and clinical samples. Examining different clinical groups would facil- boundaries of these relational sources of self-worth as well as to itate the identification of both general and specific factors asso- increase the dominance of other sources of self-worth (e.g., ciated with ROCD symptoms. Laboratory and longitudinal studies academic, physical). should further examine the hypothesized causal and correlational Particular emphasis should be given to softening attachment relationships proposed in this paper. worries and anxieties, mainly fear of abandonment (see Doron & This conceptual framework has focused on a relatively new Molding, 2009, for a description of Attachment-based CBT). Help- area of OCD related research. Our aim is to enhance our under- ful strategies may include challenging the link between OCD- standing of OCD phenomena by drawing attention to what we related beliefs and abandonment fears (e.g., “over-vigilance will believe is an important OCD theme-relationships. 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